Professional Documents
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Sexually Transmitted Infections
For the Ethiopian Health Center Team
Melake Demana, Negga Baraki, Yared Kifle, Fetih Mohammed, Mulusew Getie,
Eyob Akililu, Selamawit Debebe, Tamirat Gebru, Mengistu Welday,
Alemayehu Galmessa, Yonathan Tadesse,
Zinabue Anamo, Fikru Tesfaye
Haramaya University
In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education
2002
Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.
Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.
All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.
This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.
TABLE OF CONTENTS
TOPIC PAGE
i
ACKNOWLEDGEMENT
The authors are grateful to The Carter Center for the financial, material, moral
and expert assistance without which it would have been impossible to develop
this module.
We would like to extend our gratitude to Dilla College of Teachers’ Education and
Health Sciences, Jimma University and Gondar College of Medical Sciences for
hosting the consecutive workshops which formed the basis for this module. The
authors would like to appreciate the relentless assistance of Alemaya University
in creating conducive working atmosphere for the successful accomplishment of
this module.
We also deeply thank Phyllis Long, Jacobs Troy A. (Dr.) Tadesse Anteneh (Dr.),
and Abebe Shume for reviewing the contents of the whole draft of the module
and providing us with valuable comments which brought it to this final shape.
We are also indebted to members of the AIDS and other Sexually Transmitted
Infections (STIs) Prevention and Control Team of Ministry of Health of
Ethiopia,for their contribution in the review the draft.
We would like to extend our gratitude to W/t Tinebeb Reta for typing the
manuscript.
Finally, it is our pleasure to acknowledge those who have been in touch with us
in the module preparation in one way or another.
ii
UNIT ONE
INTRODUCTION
The basic and general concepts about STIs, their etiologic agents, epidemiology,
clinical features, diagnostic methods, treatment, and prevention and control strategies
are discussed in a simple and comprehendible way. It can also be used by other health
professionals. It should be noted, however, that it is not a substitute for standard text
books. The module can also be used as a resource for professionals working in health
centers. It may also be used as learning material in training, workshops and seminars
for members of the health center team and community health workers and as a source
of information for care givers and patients.
1
Part II: The questions are prepared for the specific categories: health officer (HO),
public health nurse (PHN), and medical laboratory technician (MLT).
Select and do the questions of the portion indicating your professional category.
¾ When you are sure that you are through with the core module proceed to read
the satellite module corresponding to your profession or interest. However, the
satellite module for environmental health technicians is not included here. It is
believed that the contents in the core module are sufficient for environmental
health technicians.
¾ Go through the task analysis for the health center team members and compare it
with that of your own.
N.B.
¾ You may refer to the list of abbreviations and glossary at the end of the module
for terms that are not clear.
¾ Questions specific to Environmental health Technician (EHT) are not prepared,
because, no specialized task is deemed for this category in the module.
2
UNIT TWO
CORE MODULE
2.1. Pre-test
Write “True “ or “False “ for question 1 - 12, write the letter of your choice for questions
13 - 17; fill in the blanks for questions 18 - 20 and write short answers for questions
21 -27.
1. Contracting an STI increases the risk for acquiring HIV/ AIDS
2. Gonorrhea and chlamydia infections are usually a symptomatic in men.
3. The syndromes approach is the most perfect diagnostic method for the
management of STI even in the health institutions with sophisticated laboratory
facilities and with well trained health personnel.
4. STIs are not significant public health problems in Ethiopia now as a result of the
high level of awareness created for HIV/AIDS control.
5. Pubic lice is a sexually transmitted ecto-parasite.
6. Patients with asymptomatic STI can be a source of infection for their sexual
partners.
7. There are only two stages in the clinical presentation of syphilis.
8. The ulcer in syphilis is soft and tender.
9. Women are often asymptomatic for chancroid.
10. Ophthalmia neonntorum can cause permanent damage to eyes including
blindness.
11. The syndromic approach is largely based on a patient’s history.
12. Post-coital genital washing is as effective as using condoms in preventing STIs.
3
13. Taking antibiotics prior to sexual intercourse can prevent STI.
14. Which of the following statement is false?
A. STIs rank 2nd to malaria in their socio economic impact in tropical
communities.
B. In developing countries STIs constitute 15% of the disease burden especially
in the urban population.
C. Globally women have less STI disease than men.
D. None of the above
4
18. Which of the following is the best approach to health education in the prevention of
STIs?
A. Transfer of information by professionals to the community
B. Health education in the form of dialogue
C. Participatory way of health education
D. Health education using mass media
E. B and C
19. List two common symptoms of urethritis: ___________ and ___________
20. ______________________ refers to an acute clinical syndrome that results from
ascending infection from the cervix and/or vagina.
21. _______________ and _________________ are usually causes of scrotal
swelling.
22. What factors contribute to the increasing in STI? (List 5)
23. Define Sexually Transmitted Infections briefly.
24. Write the major advantages of syndromic management.
25. Mention at least four methods of STI prevention and control
26. Which population groups at risk of STI infection need specific services?
27. Who are the most influential people in the community to help in public awareness
programs for the prevention of STIs?
28. Why is it so important to control STIs.
N.B. No specific questions are set for Environmental health Technicians since
preparation of separate satellite module is not found to be essential.
5
2. The drug of choice for vaginal discharge is Benzathine Penicillin.
A. True B. False
3. Thick white ‘cheesy’ odourless vaginal discharge is characteristic of candidiasis.
A. True B. False
4. A recent new partner is one of the risk factors for acquiring STI.
A. True B. False
5. Which of the following is intracellular Gram –ve organism?
A. T.Pallidum
B. N. gonorrhea
C. C.trachomatis
D. Phithrus pubis
E. B and C
6. Lymphograuloma venerum is caused by:
A. H.ducreyi
B. C. trachomatis
C. Human papilloma virus
D. Calymmatobacter granulomatis
E. None of the above
7. Which of the following diseases does not produce inguinal bubo?
A. Herpes genitalis
B. Lymphogranuloma venereum
C. Chancroid
D. Granuloma Inguinale
E. Syphilis
8. Painful genital ulcer is caused by
A. Hepatitis B virus
B. H-duereyi
C. T. pallidum
D. C. trachomatis
E. B and C
6
9. Vaginal discharge syndrome is caused by:
A. Gonorrhea
B. Trichomoniasis
C. Candidacies
D. Chlamydial infection
E. All of the above
10. A 20 year old female presented with fever and vaginal discharge. On examination
she has cervical motion tenderness and uterine tenderness. This patient should be
considered as a case of
A. Inguinal bubo syndrome
B. Vaginal discharge syndrome
C. Lower abdominal pain syndrome
D. Genital ulcer syndrome
E. B and C
11. Which of the following is least essential for syndromic management of patients with
STI?
A. Laboratory investigations
B. Proper history
C. Physical examination
D. Follow up of patients
E. None of the above
12. Which of the following drugs should not be used during pregnancy?
A. Benzathine Penicillin
B. Ampicillin
C. Tetracycline
D. Erythromycin
13. Gram stain of abnormal vaginal discharge might detect
A. Gonococcal infection
B. Candidial infection
C. Syphilis
D. Trichomoniasis
7
14. The primary ulcerative lesion in syphilitic infection is known as _____.
15. Genital ulcers preceded by vesicles are typical for _______.
16. List the common bacterial causes of STIs.
17. List the major advantages of the syndromic approach to STIs.
18. List the two most common causes of urethral discharge syndromes.
19. List some of the potential complications of properly untreated STIs.
20. Explain the link between STIs and HIV infection
Write the best single answer of your choice for questions 1 – 10.
8
2. A false negative result in the examination of urethral discharge could be caused by:
A. Incorrect labeling
B. Inappropriate staining technique
C. Collection of specimen before urination
D. A and B
E. All
3. Before collection of a sample from patients with lesions for diagnosis of T.pallidium,
the area should be cleaned with
A. Savlone
B. 70% alchol
C. Physiological saline
D. Cleaning is not important
E. None
4. The antigen supplied with the RPR kit should be stored at what temperature?
A. Room temperature
B. 2° - 8° C
C. -20°C
D. 37°
E. None
5. N.gonnorea from urethral discharge is diagnosed by:
A. Gram's staining technique
B. We mount preparation
C. Culture
D. A and C
E. None
9
7. Identification of gram negative intracellular diplococci in urethral or cervical
discharge is suggestive of:
A. T.Pallidium
B. C.albicans
C. Chlamydia species
D. N.gonnorea
E. T.vaginalis
8. The safety precaution that should be considered when collecting and handling
specimens include
A. Wear a rubber glove
B. Cover any skin break on the hands
C. Give extra care
D. All
E. None
10. In the RPR test for syphilis, false positive reaction could be caused by
A. Leprosy
B. Tuberculosis
C. Malaria
D. Pregnancy
E. All
10
2.2. Significance and Brief Description of the Problems
Sexually transmitted infections (STIs) remain a public health problem of major
significance in most parts of the world (1). There continues to be an increasing trend
because of factors such as the following: (5).
¾ Many more people live in or travel to large cities and they are often separated
from their families.
¾ Many people become sexually active before marriage.
¾ The impact of drug resistance.
¾ Low level of awareness about STI.
¾ Lack of behavioral change among sexually active individuals etc.
In the 1993 world development report, it is estimated that, in developing countries STI,
(excluding HIV), accounted for 8.9% of the disease burden in women aged 15-49 years
and 1.5% in men of the same age class. This ranked STIs, excluding HIV, as the
second major cause of lost disability-adjusted life years in women of reproductive age.
The vast majority of the disease burden from STIs is a result of the complications and
sequel that may follow infection: for example primary infections with gonorrhea and
chlamydia in woman is usually a symptomatic. When left untreated, however, infections
may migrate upwards from the lower reproductive tract and lead to pelvic inflammatory
disease (PID).
STIs are a priority not only because of their wide prevalence but also because they are
easily treatable if affected individuals reach a health service provider. In developing
countries, the laboratory diagnosis of most conditions can be difficult. Even where test
results are available, the time it takes to receive results often delays treatment of STI
cases. (1).
11
A fundamental goal of STI control programs is early detection and treatment of the
infection, preferably at the point of the patients first contact with the health system. (1).
Therefore, an effective and efficient public health program needs a tool that is rapid,
inexpensive, simple, accurate and allows STI treatment to be implemented on a large
scale by health providers with diverse levels of expertise and training. In our case the
syndromic approach is the appropriate one.
Ato Maru, a 43-year-old man, presented to a health center with a problem which he
called "Ye wond beshita" (literally, meaning disease of man). His symptoms were pussy
urethral discharge with burning sensation on urination of 5 days duration. Prior to his
presentation, he visited local small private clinic where he was given unspecified tablets
and he took 5 of them at once orally. His condition didn't improve but rather got worse
over subsequent few days.
12
He admitted, after repeated questioning, that he had been having extramarital sexual
intercourse secretly with one of the young women in the village, who was a widow. The
patient said that he couldn't acquire the disease from this woman because, he thought,
she was healthy and he had never heard her complaining about any health problem.
Rather he believed that he got this problem after he urinated facing the moon the night
before his illness. He denied any knowledge about condoms.
He was a father of 6 daughters and 5 sons, highly respected and living in one of the
small village in his locality with his wife and 5 of his children. The rest of his children
were married and living in the same village.
13
2.6. Epidemiology
Sexually transmitted infections remain a public health problem of major importance in
both developed and developing countries, but are specially so in developing countries
where access to diagnostic and treatment facilities is inadequate, very limited or non
existent at all. In many developing countries throughout the world STIs rank among the
top ten conditions for which adults seek health care. These diseases are important for
three reasons, because of their magnitude, their potential for causing serious
complications and their linkage with HIV/AIDS. According to a WHO report, in 1995 an
estimated 340 million new cases of the five most common curable STIs occurred
globally in both men and women of 15 - 49 age range. On average an estimated
930,000 people are infected every day with curable STI globally.
Prevalence figures for specific STIs are often lacking or unreliable. However, screening
of pregnant women in many parts of Africa have revealed prevalent rates of up to 10%
for syphilis, and 10 - 20% in some areas for gonorrhea.
These STIs include gonorrhea, chlamydial infection, syphilis and trichomoniasis. Out of
these 340 million STI cases, 151 million are found in South and South East Asia, 69
million in Sub-Saharan Africa and 38 million in Latin America and the Caribbean
countries.
14
b. Viral
¾ Herpes simplex type I and II
¾ Human pagillomavirus (genital warts)
¾ Hepatitis B virus
¾ Cytomegalovirus
¾ HIV
c. Others
¾ Trichomonal virginals (Trichomoniasis): another important sexually
transmitted agent which causes vaginitis and has also been shown to
facilitate HIV transmission.
¾ Candida albicans: can be sexually transmitted, is the cause of a common
fungal infection responsible for vulvovaginitis in women and inflammation
of the glans pines and fore skin in men.
¾ Genital scabies: an itchy condition caused by the mite sarcoptes scabies
which is frequently transmitted by close contact with an infected person.
¾ Pediculosis pubis: an itching caused by the public lice (phythirus pubis)
and transmitted through sexual contact.
The bacterial infections are curable as is trichomoniasis, scabies and pediculosis pubis.
Nevertheless, re-exposure after cure can make the illness re-occur. The viral infections
are not curable, but some can be controlled.
2.7.2. Pathogenesis
One can acquire STI after even one sexual contact with an infected person. After the
etiologic agent gets into the patient’s body, it multiphases at the site of entrance and, in
some cases spreads locally or systemically through blood vessels and lymphatic
channels. The growth and multiplication of the etiologic agent in the human body is
called infection. This incites an inflammatory reaction at the site of infection giving rise
to the characteristic features of the particular infection. Purulent urethral discharge and
dysuria in gonococci and Chlamydia infection of the urethra urethentis causes painful
15
blisters and ulcers in herpes, chancre in syphilis, inguinal lymph node abscess in LGV
etc.
Some infections can be asymptomatic, but patients with such type of infections can be a
source of infection. Similarly ectoparasites like P. pubis can be acquired by sexual
intercourse with an already infected person. They reside and multiply on the skin of the
patient causing irritation and itching, and they feed on the patient’s blood.
Urethritis caused by N. gonorrhoeae has usually an acute onset with profuse and
purulent discharge while that of C. trachomitis will be of subacute onset with scanty
16
mulopurulent discharge. However, this is not always true and mixed infections by both
organisms can sometimes occur.
17
Tertiary syphilis occurs after a variable latent period of months to years. It is
characterized by gummatous changes and arthritis. Neuro-syphilis can occur at any
time.
Pelvic inflammatory diseases (PID) refers to an acute clinical syndrome that results from
ascending infection from the cervix and/or vagina. The upper structures of the female
genital organs are affected. The term PID includes endometritis, parametritis,
salphingitis, oop[horitis (Editor’s note: what is the spelling?), pelvic peritonitis,
tuboovarian abscess and inflammation around the liver, spleen or appendix.
18
The common pathogens associated with PID, which are transmitted through the sexual
route, include N. gonorrhoeae, C. trachomitis, M. homonis, and Bacteroides.
The causes of scrotal swelling from STI are usually N. gonorrhoea and C. trachomatis;
when infected, the testis becomes swollen, hot and very painful. However, other
infectious causes of scrotal swelling could be brucellosis, mumps, onchocerciasis or
infection with W. bancrofti, or tuberculosis that are not sexually transmitted.
It is important to exclude other causes of scrotal swelling like testicular torsion, trauma
and incarcerated inguinal hernia as they may require urgent referral for proper surgical
evaluation and treatment.
Inguinal bubo is a swelling of inguinal lymph nodes as a result of STIs but it should be
remembered that infections on the lower extremities or in the perineum could produce
such swelling. The common STI pathogens causing inguinal swelling include: T.
pallidum, C. trachomatis (serovars 1, 2 and 3), H. ducreyi and C. granulomatis.
Surgical incisions are contraindicated and the pus should be aspirated using a
hypodermic needle.
Ophthalmia neonatorum is the term used to describe a condition where a baby develops
purulent conjunctivitis in one or both eyes within four weeks of birth. If the baby is older,
the cause is unlikely to be an STI. It is a medical emergency unless treatment is initiated
within 24 hours. There could be permanent damage to the eyes including blindness.
The neonate develops infection of the eyes during birth as a result of genital infection of
the mother with N.gonorrhoea or C.trachomatis.
19
2.9. Diagnosis
20
In view of the above facts it is preferable to use syndromic approach based on clinical
features.
As it is stated in the above (in Section 2.9) the syndromic approach is a preferred way of
managing STI cases.
The syndromic case management provides health workers in low-resource settings with
a practical tool to improve diagnosis and treatment. It uses common symptoms of STI
as a starting point and, using a flow charge, an STI management decision is arrived at.
In addition to treatment, counseling about STI prevention, partner notification and
control provision are essential parts of syndromic case management.
21
2.11. Prevention and Control of STI
The popular saying "Prevention is better than cure" is very true in the case of STIs.
Prevention of STI must remain as a priority that goes beyond individual behavior
change. The programs must address the root causes of the problem.
The strategies to reduce STI /HIV are complimentary as they aim to avoid unsafe sex
and limit the number of sexual partners. The following are components of the public
health package of STI prevention and control.
Use of condoms should be promoted and they should be available in any health care
facility providing STI prevention services. Instructions about the proper use of condoms
should also be provided, where feasible (condoms should be provided free of charge).
22
Fig: In Cambodia trainers from a hospital demonstrate proper use of condoms to taxi
drivers at a market in SVAY RIENG province.
Source: Net work family health international volume 20, Number 4, 2001,
Education forms the backbone of control of STI. The involvement of the lay public is
imperative. The awareness about the STI and sex in particular is very vital. A variety of
methods can be used for the purpose, comprising public education, briefings at religious
places, news items and documentaries on television and radio. Sex education should
be a major topic in the school and college curriculums. The public and patients should
be encouraged to seek appropriate health services provided by health institutions.
Explaining to the clients the association between STI and HIV, that it is the same risky
behaviors that are responsible for acquisition of these two conditions is also an
important element in the prevention of STI/HIV. Clients should be educated on safe
sexual behavior: abstaining from sexual activity, maintaining a mutually faithful sexual
relationship, engaging only in safe sex acts such as non- penetrative or having sex only
with the use of condom.
23
Remember the ABCs of prevention of STI:
Be mutually faithful. Always have sex with the same person. This person also must not
have sex with any one else and must not have an STI.
(Important: You usually can not tell if a person has an STI just by looking at him or her.
People with STI, including HIV, usually do not look sick.)
Consistently use condoms, use them every time and use them correctly
Health care approach to health education stresses dialogue, not just the transfer of
information and this participation or community involvement in decision making may
provide the best results in the prevention of STI.
Early detection and treatment of cases is very important. It prevents more serious
complications in patient’s, and it benefits the community by preventing further
transmission.
Whatever the overall STI/HIV prevention and control strategy, counseling should be a
major integral part. Specific counseling activities will depend on the individuals and
groups to be addressed together with the content to be emphasized and the manner in
which counseling is to be provided. In addition, the availability of technical resources,
24
financing, and an infrastructure within which counseling can be provided will all need to
be taken into account.
Counseling has to be part of all strategies for preventing STI/HIV infection. Most people
with STI/HIV infection do not know that they are infected. Until now, only a small
percentage of those with identified STI/HIV infection or disease have had access to
reliable counseling services and, therefore, to the support necessary for changes in
behavior. The continued development of counseling services is therefore important to
the prevention of STI/HIV.
6. Integration of STI prevention into primary health care, reproductive health care
facilities, private clinics and others.
25
UNIT THREE
SATELLITE MODULES
¾ Before reading this satellite module be sure that you have completed the pre-test
and studied the core module.
¾ Continue reading this satellite module and upon completion do the pre-test as a
post-test.
Upon completing this module the Health Officer will be able to:
¾ Describe the etiology of STI
¾ Explain the pathogenesis of STI
¾ Identify clinical features and classify then according to syndromes.
¾ Describe management of STIs according to the syndromic approach.
¾ Explain the link between STI and HIV/AIDS.
After taking history of the patient, the health officer continued with physical examination.
The health officer examined the patient and detected the following findings. The
external genitalia were mildly tender. On squeezing purulent discharge is expressed
from the urethra. There is no ulcer over the genital area and the scrotum is normal.
Inguinal examination revealed no swelling or tenderness.
26
Questions
1. What is the probable diagnosis of this patient?
2. What should be the management of this patient?
3. Does this patient need laboratory tests? Why?
The Health Officer treated the patient with spectromycin infection and tetracycline
tables. He also discussed the causes of his problem and convinced him to bring his
sexual partner the next day.
The next day the Health Officer examined the partner and found a painless ulcer on the
vulva. There was no vaginal discharge. The inguinal areax were normal and there was
no other abdominal finding.
3.1.4.1. Etiology
STI are a group of communicable diseases that are transmitted predominantly by sexual
contact and caused by a wide range of bacterial, viral, protozoa and fungal agents and
ectoparasites.
Bacterial causes Disease
¾ Neisseria gonorrhea Gonorrhea
¾ Chlamydia trachomatis Urethritis and
Lymphogranuloma-
venereum (LGV)
¾ Treponema pallidum Syphilis
¾ Haemophilus ducreyi Chancroid
¾ Calymmatobacterium granulomatis Granuloma Inguinale
¾ G.vaginalis and other normal flora of vagina Bacterial vaginosis
27
Viral Causes Disease
¾ HIV 1 and HIV 2 HIV/AIDS
¾ Herpes simplex virus (type 1 and 2) Genital herpes
¾ Human papilloma virus Condylomata accuminata
¾ Hepatitis B virus Hepatitis
3.1.4.2. Pathogenesis
Only the most important organisms will be dealt with in this chapter.
N. gonorrhea is anintracellular Gram -ve diplococci. Initially the organism attaches to the
columnar mucosal cells. Then, it penetrates and proliferates inside the cells. This results
in local inflammatory response or systemic manifestations (1, 5).
N.B. N.gonorrhoea and C.trachomatis can ascend to the upper genital tract and
establish infection in the endometrium (endometritis), fallopian tubes and ovaries
(salphingitis) and pelvic peritoneum. These result in pelvic inflammatory disease.
28
T. Palladium is a spirochete organism and it rapidly penetrates intact mucous
membranes or gains access to subcutaneous tissues via microscopic abrasions that
occur during sexual intercourse. It multiplies locally and the initial ulcerative lesion
(Chancre) develops which gives Primary Syphilis. At the same time some organisms
travel to and establish infection in regional lymphnodes. These local infections induce a
host immune response that produces antibodies which may be detected in serum.
Inspite of these host responses wide spread hematogeneous dissemination of the
organisms occurs. This gets the basis for the development of later stages of syphilis
(secondary and tertiary syphilis).
All of the above organisms have varying clinical features. Traditionally the clinical
approach was how a diagnosis was reached with or without laboratory support. This has
several drawbacks:
¾ It relies on the provider’s clinical judgment which can bring an incorrect
diagnosis.
¾ A single STI is usually identified and treated where there may be multiple causes.
¾ It might require laboratory facilities which may be expensive. Treatment is usually
delayed because of the time it requires for laboratory investigations.
Therefore a syndromic approach to diagnose and treat STIs has been recommended by
the WHO since 1990.
29
¾ It decreases the need for referring patients to higher health institutions.
¾ It is easy to teach and simple to apply.
Clinical Features
It is a discharge from the penis with or without painful urination (dysuria). Usually the
patient complains of urethral discharge and/or dysuria and the Health Officer should ask
for any history of sexual contact. On examination urethral discharge may be observed. If
not, the penis should be milked to confirm the presence of discharge. Redness and
swelling of the urethral meatus (opening) is usually observed. The Health Officer should
also look for other signs of STI like genital ulcer and inguinal L/N enlargement etc.
The most common causes of urethral discharge in man are gonorrhea and chlamydial
infection. In chlamydial infection symptoms of urethral inflammation occur between 7 -
28 days after sexual intercourse. It gives scanty whitish mucoid discharge associated
with dysuria and urethral discomfort. The discharge is usually marked in the morning.
30
In Gonococcal infection symptoms start between 2 - 10 days after sexual contact.
The discharge is usually yellowish white with severe burning sensation on micturation.
Management
Use the flow chart for urethral discharge syndrome (Annex II flow chart 1).
Clinical features
Normally a clear and odourless vaginal discharge can occur at certain phases of the
menstrual cycle, during sexual activity, during pregnancy and lactation. But in vaginal
discharge syndrome the patient complains of discharge that may have a different
colour, odour, consistency or amount more than normal discharge. It can also be
associated with vaginal itching, painful urination and pain during sexual intercourse.
Possible risk factors should be identified. These can be a symptomatic partner, recent
new partner and multiple sexual partners.
If there is genital ulcers, consider genital ulcer syndrome. If there is associated lower
abdominal pain and cervical motion tenderness, consider vaginal discharge syndrome.
31
some urinary symptoms like dysuria and frequent urination. Bacterial vaginosis results
in a malodorous (fishy odor) and whitish mucoid discharge of moderate amount.
Management
Use the flow chart for vaginal discharge syndrome (Annex II flow chart 2-1).
Clinical Features
The patient complains of sores or ulcers on the genitalia which might be painful or
painless. On examination the health office may observe a genital ulcer or multiple
ulcers. These ulcers might be associated with vesicles or swollen inguinal lymph nodes.
This syndrome is mainly caused by primary syphilis, chancroid and genital herpes. The
incubation period for development of ulcer in the case of syphilis is 1 - 13 weeks
(usually 3 - 4 weeks). Chancroid and herpes are 4 - 7 days after a sexual contact.
Primary Syphilis usually gives a painless, firm ulcer whereas ulcers due to chancroid
are painful and soft that easily bleed. However, in women it might be painless. In
Herpes genitalis, vesicles proceed the development of ulcers. When the vesicles
rupture they leave ulcers that are multiple, small, round and painful. Frequent
recurrence is common in genital herpes especially in patients with HIV/ AIDS. Genital
ulcers can be secondarily infected and this might obscure the typical clinical
presentation.
32
In syphilis and chancroid inguinal lymphnodes might be enlarged. In syphilis this is
usually painless and firm, but in chancroid it is painful and may discharge pus.
Genital ulcer may also be caused by granuloma inguinalae (donovanosis) and LGV
(lymphogranuloma venereum).
Management
Use the flow chart for genital ulcer (Unit 7.2 flowchart 3).
Clinical Features
The common causes of this syndrome are gonorrhea, chlamydial infection and
anaerobic bacteria infections.
N.B. Surgical emergency causes of lower abdominal pain should be ruled out
Management
Use the flow chart for lower abdominal pain syndrome in women (Unit 7.2 flowchart 4).
33
E. Scrotal swelling syndrome:
Clinical features
The testis, when infected, becomes swollen, hot and excruciatingly painful. Patients
may become sub fertile if quick and effective therapy is not given. This syndrome is
commonly caused by N. gonorrhea or Chlamydia. It can also be caused by Escherichia
coli and mumps virus.
Management
Use the flow chart for scrotal swelling syndrome in women (Unit 7.2 flowchart 5).
Clinical features
The common causes of this syndrome are Lymphogranuloma venereum and chancroid
and Granuloma inguinale. In syphilis inguinal lymph node enlargements are painless
and do not produce pus. It should be remembered that infections on the lower
extremities or on the perineum could produce swelling of the inguinal lymph nodes.
Management
Use the flow chart for inguinal bubo syndrome (Unit 7.2 flowchart 6).
34
G. Ophtalmia neonatorum
Clinical features
Management
Use the flow chart for Ophtalmia neonatorum (Unit 7.2 flowchart 7).
Disease Complication
Gonorrhoea - Disseminated gonococci infection epididymitis and orchitis
- Conjunctivitis in newborn
- PID and infertility
- Urethral stricture in men
Syphilis o o
- 2 / 3 syphilis
35
3.1.7. The Link between STIs and HIV/AIDS
It is now clear that HIV/AIDS and other STIs have bi-directional relations. The
transmission of HIV is influenced by the presence of other STIs and the course of other
STIs is influenced by the presence of HIV in patients. Data from a number of studies
strongly suggest that the presence of both ulcerative and non-ulcerative STIs facilitate
the transmission of HIV. Some studies have shown that there are two to nine times
increased risk of acquiring HIV when patients have other STIs. This may explain why
HIV infection is prevalent in Africa where STIs' control and management programs are
underdeveloped.
On the other hand the clinical pictures of many STIs are modified by the presence of
HIV infection. STIs tend to progress quickly resulting in early development of
complications. They also tend to be more chronic. Patients with STIs co-infected with
HIV do not respond favorably to conventional treatment, e.g. patients with HIV and
Syphilis sometimes fail to respond to single dose treatment of with Benzathine penicillin.
Patients have greater incidence of drug allergy making it difficult for the health care
provider to give affordable drugs.
Therefore, programs to combat STIs should include HIV/AIDS as one of the most
important components. The health officer should understand the link between STIs and
HIV/AIDS and predict the outcomes of patients with these conditions so that early
management of cases and their complications can be applied.
Now you are through with the core and satellite modules, but there are still some
activities remaining as stated below.
1. Read the task analysis of the different categories of the Health Center Team on
Unit 4.
2. Do the pre-test as a post-test.
N.B: Use a separate answer sheet.
3. Compare your answers from the pre- and post-tests with the answer keys given on
Unit 7.3 and evaluate your progress.
36
3.2. Satellite Module for Public Health Nurses
¾ Before reading this satellite module, be sure that you have studied the core
module and completed the pre-test.
37
3.2.3. Nursing considerations in the treatment of STIS
Table 3.2.1: Common side effects and nursing responsibilities related to common drugs used in
the treatment of STIs (2, 8)
No Drug Adult dose Common side effects and Nursing responsibility
Average contraindications
1 Ciprofloxacin 250 mg po BID Pregnancy, lactation, and Administer oral dose 2 hr
children less than 16 years old after or before taking
antacids, monitor, intake
and output.
2 Doxycycline 100 mg BID Renal failure, pregnancy, Give doxycycline with food
children up to 8 years Administer accurately;
give 1-2 hours after
antacid or milk.
3 Metronidazole 500 mg BID First trimester of pregnancy Caution in administering
for clients with central
nervous system disorder
4 Clotrimazole 100 mg vaginal Lower abdominal cramps, Watch for irritations or
tablet insert nausea, vomiting, mild vaginal sensitivity; educate patient
daily for 7 burning or irritation. to avoid drug from coming
consecutive in contact with eyes; tell
days patient to refrain from
intercourse.
5 Tetracycline 250-500mg Nausea, vomiting, sore mouth, Administer accurately,
QID white patches on oral mucosa, give 1-2 hours after
diarrhea, skin rashes antacid or milk; give 1-2
hrs after meal
6 Erythromycin 500mg po QID Nausea, vomiting, diarrhea, Give on an empty
base for 7 days skin rashes stomach, and with water;
minimize food intake just
before or after taking the
drug; report severe
nausea vomiting, diarrhea,
and skin rash
7 Benzathine 2.4 mu IM Hypersensitivity- anaphylaxis
penicillin G. weekly for 3 (hypotension, respiratory Give deeply into a large
weeks distress, itching, edema of muscle mass, observe for
joints, bronchospasm) may anaphylaxis serum
occur within 5 to 30 minutes of sickness.
penicillin administration.
38
3.2.4. Nursing Management of STIs (3)
Examination of patients with STIs includes general assessment of the patient, such as
taking history, symptoms, location of lesions, discharge, history of STI and self
treatment. Confidentiality is important when sexual issues are involved. Privacy is
assured during information gathering sessions. To avoid confusion and negative
implications, the nurse uses terms that patients understand, ask open ended questions,
and uses sensitivity when asking questions about persons with whom the patient has
had sexual contact.
39
Things to ask:
The following are things to ask regarding the syndromes:
¾ Urethral discharge or burning on urination in men
onset,
unprotected casual sex,
the amount of discharge ,
multiple sex partner,
history of STI in his/ her partner.
¾ Vaginal discharge
Onset,
change in color, amount, and odor,
multiple sexual partner,
change in partner,
sex without condom.
¾ Genital ulcer in men and women
onset,
history of recurrence,
presence of pain,
location,
multiple or clustered ulcers.
¾ Lower abdominal pain in women
onset,
PQRST
- Pain type,
- Quality of pain,
- Radiation of pain, and relief of pain,
- Symptoms associated with pain,
- Timing of pain
presence of vaginal discharge,
last menstrual period (LMP), and
systemic symptoms like fever, nausea, and vomiting.
40
¾ Scrotal swelling
onset,
presence of pain,
history of trauma, and
concomitant urethral discharge.
¾ Inguinal bubo
Presence of pain,
ulceration,
discharges, and
the location of swelling.,
¾ Ophtalmia neonatorum
Date of delivery,
History of purulent vaginal discharge of the mother,
History of purulent discharge from eye of the neonate.
N.B: In addition to specific questions related to syndromes, the nurse may ask about patient’s use
of traditional medicines, use of herbs or other treatments prior to seeking treatment in a
clinic; how the patient believes the treatment or approach will solve the problem.
The most common nursing diagnosis based on the assessment of patients may include:
¾ Knowledge deficit about the nature of the disease and the high risk for spread of
infection and for other STIs including HIV infection.
41
3.2.7. Nursing interventions of STIs
The following are important considerations in the nursing interventions for STIs.
42
¾ A pregnant woman with STI infections may pass the infection to her unborn baby
or during the birth process.
¾ A person who has been raped (sex with unknown person without permission)
should have check up as soon as possible.
¾ Advice a patient on importance of complying with treatment.
¾ Educate a patient not to engage in sexual activity until competently cured.
¾ Educate the patient on safer sexual behavior.
¾ Explain why it is important that the patient’s sexual partners also be treated.
i. Hand washing
Hand washing is the single most important measure of preventing the spread of
infections. The nurse should wash hands for 10 seconds with soap, running water and
friction before touching patients and any time the hands have been soiled.
ii. Gloves
Put on clean gloves just before contact with mucus membrane and non-intact skin.
Gloves are always worn while the genitalia are examined. Any discharge, secretion or
pus is considered to be potentially infectious. The body fluid and tissues of patients with
systemic STIs, HIV/AIDS, Hepatitis B Virus - HBV, cytomegalo virus - CMV infection,
syphilis and disseminated gonorrhea are regarded as potentially infectious. When digital
vaginal and rectal examinations are performed in a woman with a suspected STI, gloves
should be changed after the vaginal examination, to prevent the transmission of
gonococci chlamydia or herpes simplex virus from the cervix or vagina to the rectum.
43
iii. Specimen collection and transportation
When coming in contact with mucus membranes during delivery or examination and on
handling newborn, wear protective garments.
In any control program, data collection is an important step for the purpose of
evaluation. This represents interactive process at first utilizing baseline information. But
as the program is implemented more refined data should be available for program
evaluation. This data comes from the patients. STI patients on their presentation at the
health center are expected to be identified on the following: sex, age, syndrome (clinical
presentation), first visit or repeated consultations, or contact traced, laboratory results,
consumption of drugs, eventual failure or referral. Records should be maintained in the
health center and reports communicated as required.
What is counseling?
44
¾ Providing psychosocial support to those already affected
In order to achieve these objectives counseling seeks to help infected people make
decisions about their lives, build their self confidence and improve family and
community relationships. It certainly need not be restricted to a clinic or a structured
situation. The most successful counseling takes place outside the formal relationship.
Some issues which arise during a STI consultation may provoke emotional reactions in
the patient. The nurse should be able to recognize these and ensure that time is set
aside in a counseling session to discuss them.
45
Now you are through with the core and satellite modules, but there are still some
activities remaining as stated below.
1. Read the task analysis of the different categories of the Health Center Team on
Unit 4.
2. Do the pre-test as a post-test.
N.B: Use a separate answer sheet.
3. Compare your answers from the pre- and post-tests with the answer keys given on
Unit 7.3 and evaluate your progress.
46
3.3. Satellite Module for Medical Laboratory Technicians
¾ Before reading this satellite module be sure that you have completed the pre-test
and studied the core module.
¾ Continue reading this satellite module
General
The aim of this satellite module is to enable the learner to acquire knowledge, attitude
and practices concerning laboratory diagnosis of sexually transmitted infections.
Specific
47
3.3.4. Source and collection of samples
Source of Sample for STI diagnosis includes:
I. Discharge
II. Blood
III. Skin scrapings
3.3.4.1. Discharges
Materials Required:
¾ Dry cotton
¾ Physiological saline
¾ Cotton wool swab (sterile)
¾ Microscopic slide and cover
Procedure:
1. Clean the area round the urethral opening using a swab moistened with sterile
physiological saline.
2. Gently massage the urethra from above down wards, and collect a sample of pus
on a sterile cotton wool swab.
Note: The patient should not have passed urine preferably for 2 hours before the
specimen is collected.
3. Make smear of the discharge on a slide. While making a smear, care should be
taken not to damage pus cells because presumptive diagnosis of gonorrhea is
made if Gram negative diplococci are found inside pus cells. Therefore, roll
gently the swab of the discharge on the slide. Fix the smear with methanol, not
with heat.
4. Label the specimen
5. Perform gram stain of specimen.
Source of error:
¾ Incorrect labeling.
¾ Collection of specimen just after urination.
48
¾ Inappropriate staining technique.
¾ Heat fixation
¾ Wrong smear preparation
Although the specimen collection should be done by clinicians (HO, Nurses), laboratory
technicians are anticipated to know the procedure.
Material required:
¾ Speculum
¾ Dry cotton
¾ Physiological saline
Procedure:
1. Moisten a vaginal speculum with sterile warm water, and insert into the vagina.
2. Cleanse the cervix using a swab moistened with sterile physiological saline.
3. Pass a sterile cotton wool swab into the endo-cervical canal and gently rotate the
swab.
4. Make a smear on a slide for staining by the Gram technique.
5. Label the specimen.
Sources of error:
¾ Incorrect labeling.
¾ Unrepresentative sample.
¾ Inappropriate staining technique.
¾ Heat fixation.
¾ Wrong smear preparation.
49
C. Collection of vaginal specimen
Material required:
¾ Microscopic slide
¾ Cover slide
¾ Cotton wool swab
¾ Physiological saline
Procedure:
¾ Collect a sample of vaginal discharge on a sterile cotton wool swab.
¾ If the discharge is collected for Gram’s technique, make a smear on a slide.
¾ If it is for wet mount preparation, mount a small sample on a slide, add one drop
of physiological saline, and cover with a cover glass.
Sources of error:
¾ Unrepresentative sample
¾ Failure to examine the preparation immediately
¾ Incorrect smear
¾ In correct preparation technique
Material required
¾ Tourniquet
¾ 70% alcohol
¾ Sterile needle and syringe
¾ Test tube
¾ Dry cotton
Procedure:
¾ Clean the area with swab moistened with 70% alcohol.
¾ Collect 2 - 3 ml of venous blood with sterile syringe and needle.
¾ Transfer to a clean, dry test tube and allow to stand at room temperature for at
least 1 hour.
¾ Centrifuge the sample after breaking the clot.
50
¾ Separate the serum from the clotted blood into another clean dry test tube.
Note: If the serum is contaminated with red cells, re-centrifuge the serum. Any lipemic
or haemolysed specimen should be rejected.
The diagnosis of syphilis depends on the identification of the organism by dark field
microscopy or detection of the serological response due to the infection. Based on the
type of antibody response which occurs in patients with treponemal infection, there are
two main types of serological tests to diagnose syphilis.
¾ Non treponemal (Cardiolipin) antigen tests Eg. RPR, VDRL (Non specific
tests)
¾ Treponemal antigen tests E.g. FTA, TPHA (specific tests)
At the health center level most of these laboratory tests for T-pallidum are not
applicable.
Principle:
51
Storage of reagents:
Precautions:
¾ Before use, shake the RPR antigen gently.
¾ Samples and reagents should be brought to room temperature before use.
¾ The test card should be preferably stored at room temperature once the kit is
opened.
¾ After use the dispensing dropper should be cleaned with distilled water, dried and
stored properly.
Procedure:
¾ Dispense 0.5 ml of the sample (plasma or serum) onto a circle of the test
card using a clean and dry pipette.
¾ Add one drop of the RPR antigen onto the sample, while holding the dropper
in a vertical position. Do not restrict the mixture on the test circle.
52
3.3.5.2. Laboratory diagnosis for HIV
Diagnosis of HIV infection is generally made serologically. Some of them are ELISA,
HIV dot and Agglutination tests. These tests can be confirmed with a more specific
serological tests such as western blot. But most of these laboratory tests are not
applicable at the health center level.
HIV Tri-dot
It is a simple and rapid (5 minutes) HIV-1 and HIV-2 antibody test with separate test
areas for HIV-1 and HIV-2.
Principle
Recombinant HIV-1 and HIV-2 protein antigens are immobilized on a porous immuno-
filtration membrane to detect separately antibodies to HIV-1 and HIV-2 in serum or
plasma. When a drop of sample is added it flows through the membrane and antibodies
bind to the HIV antigen forming an immune complex. The reaction is visualized by
passing gold conjugate (pink) reagent through the membrane which binds to the HIV
antibodies. A reactive test (positive test) is shown by a pink dot in the HIV-1 and / or
HIV-2 test areas. Each test device has a built in quality control dot which develops color
during the test, confirming that the procedure has been performed correctly and the
reagents are functioning satisfactorily.
Materials provided
- Test devices
- Buffer solution
- Gold conjugate
- Disposable pipette
Procedure
(See figure 3.3.1 for details)
- Add 3 drops of buffer solution into device.
- Add 1 drop of patient sample (serum or plasma) using a dropper provided.
- Add 5 drops of buffer solution and allow it to soak in.
- Add 2 drops of gold conjugate solution, allow it to soak in and add 3 drops of
buffer solution.
53
Reporting results
¾ If there is no pink dot in the HIV-1 and HIV-2 test areas the test is interpreted as
negative (non-reactive).
¾ If there is a pink dot in the HIV-1 test area, the test is reactive for HIV-1. The test
can be reactive for HIV-2 if the pink dot is seen in the HIV-2 test area and it can
also reactive for both HIV-1 & HIV-2 if the pink dot is seen in the HIV-1 and HIV-2
test areas.
¾ If no pink dot is seen in the control area the whole test is invalid. This indicates
that there is a procedural error or deterioration of reagents. So the sample should
be tested again with a new device and reagents.
54
Figure 3.3.1: procedures (Steps) in HIV tri-dot test.
55
3.3.5.3. Laboratory diagnosis for N.gonnorea
Direct Microscopy
Procedure:
¾ Prepare a smear from cervical or urethral discharge.
¾ Allow to air dry
¾ Fix the air dried smear with methanol.
¾ Stain with Gram stain technique (see annex I).
¾ Examine under high power (100x) objective
Reporting result:
Report as ‘Gram negative intercellular diplococci is seen’ (per high power field), if they
are seen.
Report as ‘No Gram negative intracellular diplococci is seen’ (per high power field) if
they are not seen.
Culture
Wet mount
Procedure:
¾ Transfer the vaginal discharge collected on a slid. Add a drop of saline and cover
it with cover slip.
¾ Examine the preparation immediately after sample collection.
¾ Look for an oval, pyriform or spindle-shaped organism with a size larger than a
neutrophil leukocyte and smaller than an epithelical cell.
¾ In fresh specimen the organism (T.vaginalis) is motai.
56
Reporting result:
¾ Negative for T.vaginalis, if the organism is not seen.
¾ Positive for T.vaginalis, if the organism is seen.
Direct microscopy
Diagnosis of skin and mucous membrane infection is made by direct visualization of the
organism on scrapings following KOH preparation or by Gram’s stain.
Procedure:
¾ Smear the exudates or discharge on a clean slide.
¾ Allow air dry.
¾ Gram stain (see Unit 7.3).
¾ Look for yeast cells.
Reporting result:
In positive result Gram positive small, oval budding cell is observed under high power
filed.
No Gram negative intracellular diplococci are seen per high power field, if they are not
seen.
Negative: if no small, oval budding cell or hyphae seen.
Positive: if hyphae or small, oval budding cell seen.
KOH examination
Procedure:
¾ Place skin scrapings on a slide.
¾ Add a drop of 10% potassium hydroxide.
¾ Apply cover slide.
¾ Examine the preparation under the microscope with the low power objective.
57
Reporting result:
Negative if no oval, budding yeast cells and psudohyphae are seen.
Positive if budding yeast cells or hyphae are seen
Not available at the primary health center level. Even it was available, these tests will
not aid in the initial decision to treat the patient, as there is a delay of two or more days
in obtaining the results specially for the culture.
Serologic tests
A wide range of serological tests is now available for the detection of HBV associated
antigens, especially HBsAg, in serum collected during the acute stage of infection. But
these tests are not available at the primary health center level.
The quality control techniques that are performed in the laboratory ensure that
resources are not wasted and results are obtained at the earliest possible stage.
The control measures should encompass the pre-test and post-test activities in addition
to the control techniques on the methods while performing the test.
58
¾ Reporting and recording results.
Individuals who collect specimens should be provided with assistance and written
instructions regarding the correct type of specimen to collect, the best time to collect it,
and the aseptic method of collection to avoid contamination. Guidelines should also be
issued regarding the storage and transport of specimens, especially the use of
preservatives and transport media to ensure the viability of pathogens.
In consultation with clinical staff and regional laboratory, reporting and recording results
should be standardized to ensure reproducibility and avoid differences in interpretation.
Now you are through with the core and satellite modules, but there are still some
activities remaining as stated below.
1. Read the task analysis of the different categories of the Health Center Team on
Unit 4.
2. Do the pre-test as a post-test.
N.B: Use a separate answer sheet.
3. Compare your answers of the pre- and post-tests with the answer keys given on
Unit 7.3 and evaluate your progress.
59
3.4. Satellite Module for Community Health Workers
3.4.1. Introduction
This satellite module is prepared for the community health worker. It is hoped to provide
them with basic information on STIs including the syndromic classification and
management approach. Moreover it will help them in their active participation in
prevention and control of STIs at the community level.
¾ Start with attempting the pre-test questions. Use separate answer sheet
¾ Go through with text including the task analysis.
3.4.2. Pre-test
Use a separate answer sheet:
Choose the best answer for the following questions and write the letter of your choice
60
2. The most common STIs in Ethiopia are
A. Gonorrhea
B. Syphilis
C. Chancroid
D. All of the above
Sexually transmitted infections (STIs) are a major public health problem affecting many
people both in developing and developed world.
In developing countries, STIs are responsible for up to 15% of the disease burden in the
urban population. In tropical countries STIs rank second to malaria in their socio
economic impact. The presence of STIs increases the chance of acquiring and
transmitting HIV/AIDS.
61
In Ethiopia too, there is an increasing trend in the magnitude and intensity of STIs and
HIV/AIDS due to the following factors:
¾ Many more people living in or traveling to large cities resulting in separating
families.
¾ Many more people are becoming sexually active before marriage.
¾ Low level of awareness about STI among the public.
¾ Lack of behavioral change among sexually active individuals.
¾ The existence of strong link between STIs and the sexual transmission of HIV
infection.
STIs affect the young and the productive portion of a community leading to economic
and social problems.
After reading this satellite module the community health worker will be able to:
¾ Define sexually transmitted infections
¾ Recognize STIs as important public health problems.
¾ List common sexually transmitted infections in the community.
¾ Explain causes of STIs.
¾ Recognize that sexually transmitted infections are caused by pathogenic
microorganisms.
¾ Describe the syndromic classification and management approach of the common
sexually transmitted infections.
¾ Recognize the importance of immediate referral of cases to higher health care
facilities.
¾ Explain preventive measures of STIs.
62
The most common STIs in Ethiopia are:
¾ Gonorrhea
¾ Syphilis
¾ Chancroid
¾ Lympho granuloma venerum
They are caused by pathogenic microorganisms, which can only be seen under a
microscope. STIs are not caused by urinating facing the moon as many people believe
in our country.
A healthy person gets into a higher risk of developing STIs, when he/she:
¾ Is engaged in sexual activity with more than one partner.
¾ Does not use a condom or uses condoms incorrectly during sexual activity.
¾ Practices sex with a partner who is symptomatic; that is a person showing the
clinical features (sings and symptoms) of STIs.
Although there are more than 20 microorganisms which can be spread through sexual
contact, these different STI tend to cause similar signs and symptoms. For example,
discharge from the penis (urethra) or vagina, genital ulcer is common STI symptoms
and sings. We call such set of symptoms/signs a syndrome.
The syndromic approach to STIs consists to classification of the main STIs by the
observable syndromes they produce. The diseases are classified according to the signs
and symptoms (clinical features) they produce. The syndromes are: genital ulcer,
vaginal discharge, urethral discharge, lower abdominal pain and inguinal bubo.
The patient complains of sores or ulcers on the genitalia. They may be painful or
painless. An ulcer is a break in the continuity of the skin or mucus membrane surface.
63
The incubation period for genital ulcer varies from 4 days to 13 weeks (usually 1 to 4
weeks). In many developing countries the etiologies of genital ulcer syndrome most
frequently found are syphilis and chancroid.
The patient complains of discharge from the vagina which is different from normal in
color, odour and consistency or amount. It can be associated with vaginal itching,
painful urination and pain during sexual intercourse.
Commonly, vaginal discharge syndrome is cause by gonorrhea and other STIs like
trichomoniasis and candidiasis. Its incubation period varies from 2 days to 4 weeks.
The patient complains of discharge from the penis with or without painful urination
(burning sensation). If no discharge is found, the urethra should be milked to bring the
discharge forward.
The most common cause of urethral discharge is chlamydia and gonorrhea. The
incubation period for urethral discharge from the penis appears 2 days – 4 weeks after
sexual intercourse.
The patient may complain of fever, lower abdominal pain and tenderness as well as
vaginal discharge, pain with urination, or pain with sex. Common causes of this
syndrome are gonorrheal and chlamydial infections.
Inguinal bubo is a large swelling of the inguinal lymph nodes which may or may not be
discharging. The patient complains of swelling in one or both groin areas. It is usually
painful.
The common cause of this syndrome is T.pallidium, C.trachomatis and H.ducrey. The
incubation period varies from 10 - 30 days to several months after sexual intercourse.
64
3.4.8. Complications and problems of STIs
Some of the most common complications of STI include:
¾ If STIs are left untreated it may lead to infertility chronic pain or death in men and
women.
¾ Some STIs can be transmitted from mother to infant during pregnancy and at
birth.
¾ Can lead to some deafness and blindness in new born children.
¾ The presence of STIs also increases the likelihood of HIV transmission.
¾ Can also cause cervical cancer and abortion.
¾ Immediate referral of cases and advice to the patient to take his/her partner with
him/her for early diagnosis and treatment.
¾ Follow up of cases in terms of treatment compliance.
¾ Encouragement and advice to patients to visit health institutions in case of
treatment failure.
¾ Sexual abstinence.
¾ Avoid multiple sexual partners.
¾ Consistent and correct use of condoms.
¾ Health education on the causes and modes of transmission of STIs.
¾ Early detection and immediate referral of cases with STIs.
¾ Participate in the follow up of cases:
• treatment compliance
• treatment failure
• partner tracing
65
3.4.11. Task analysis of Community Health Workers
66
3.4.11.2. Attitude, Objectives and Activities
67
• Now you are through with the nodule, but in order to evaluate yourself you need
to do the pre-test as a post-test.
• Use a separate answer sheet.
• At last compare your answers of the pre- and post-test with the answer keys
given on Section 3.5.12 and evaluate your progress.
68
3.5. Take Home Message for Lay Care Givers
In developing countries, STIs are responsible for up to 15% of the disease burden in the
urban population. In tropical countries STIs rank second to malaria in their
socioeconomic impact. The presence of STIs increases the chance of acquiring
HIV/AIDS.
In Ethiopia too, there is an increasing trend in the magnitude and intensity of STIs and
HIV/AIDS due to the flowing factors:
¾ Many more people living in or traveling to large cities with resultant family
separation.
¾ Many more people are becoming sexually active before marriage.
¾ Low level of awareness about STIs among the public.
¾ Lack of behavioral change among sexually active individuals.
¾ The existence of strong links between STIs and the sexual transmission of HIV
infection.
STIs affect the young and the productive portion of a community leading to further
economic and social problems.
69
¾ Lymphogranuloma venereum
They are caused by pathogenic micro organisms, which can only be seen under a
microscope. STIs are not caused by urinating facing the moon as many people believe
in our country.
Although there are more than 20 microorganisms which can be spread through sexual
contact, these different STIs tend to cause similar signs and symptoms.
For example, discharge from the penis (urethra) or vagina and genital ulcers are
common STI symptoms and signs. We call such a set of symptoms/signs a syndrome.
We can classify the main STIs by the observable syndromes they produce. The
diseases are classified according to the signs and symptoms (clinical features) they
produce. The syndromes are: genital ulcer, vaginal discharge, urethral discharge, lower
abdominal pain and inguinal bubo.
70
3.5.6. Management of STIs
¾ Immediate referral of cases and advice to the patient to take his/her partner with
him/her for early diagnosis and treatment.
¾ Compliance of cases to treatment.
¾ Encouragement and advice to patients to visit health institutions in case of
treatment failure.
¾ Sexual abstinence
¾ Avoid multiple sexual partners.
¾ Consistent and correct use of condoms
¾ Awareness on the causes and modes of transmission of STIs
¾ Early treatment of cases with STIs
¾ Participate in the follow up of cases
• treatment compliance
• treatment failure
• partner tracing
71
UNIT FOUR
2 To recognize the - Describe the magnitude of - Describe the magnitude of - Describe the magnitude of - Describe the magnitude of
STIs both globally and STIs both globally and STIs both globally and STIs both globally and
public health
nationally nationally nationally nationally
importance of STIs - State the advantages of - State the advantages of - State the advantages of - State the advantages of
early detection and early detection and early detection and early detection and
treatment of STIs. treatment of STIs. treatment of STIs. treatment of STIs.
- List potential - List potential complications - List potential - List potential complications
complications of STIs. of STIs. complications of STIs. of STIs.
- Describe the - Describe the - Describe the - Describe the
interrelationship of STI interrelationship of STI interrelationship of interrelationship of STI
and HIV infection and HIV infection STI and HIV infection and HIV infection
72
Learning activities
No. Learning Objectives HO PHN ENHS MLT
4. To describe clinical -Identify general -Identify general -Identify general -Identify general
features of STI clinical features of clinical features of clinical features of STIs clinical features of STIs
syndromes STIs based upon STIs based upon based upon syndromic based upon syndromic
syndromic approach syndromic approach approach approach
5 To identify risk factors - Enumerate the risk - Enumerate the risk - Enumerate the risk - Enumerate the risk
for the transmission of factors for STIs factors for STIs factors for STIs factors for STIs
STIs - Explain the - Explain the - Explain the - Explain the
relationship between relationship between relationship between relationship between
STIs and HIV/AIDS STIs and HIV/AIDS STIs and HIV/AIDS STIs and HIV/AIDS
6. To identify the different -List the different -List the different -List the different -List the different
approaches to the approaches to the approaches to the approaches to the approaches to the
diagnosis of STIs. diagnosis of STIs. diagnosis of STIs diagnosis of STIs diagnosis of STIs
73
No. Learning objectives Learning activities
HO PHN ENHS MLT
7. Describe advantages -List the advantages of -List the advantages of -List the advantages of -List the advantages of
syndromic STI case syndromic STI case syndromic STI case syndromic STI case
of syndromic approach
management management management management
in STI management
- List the importance of - List the importance of flow chart - List the importance of - List the importance of
flow chart in the in the management of STIs flow chart in the flow chart in the
management of STIs Management of STIs Management of STIs
- Identify the different - Identify the different flow charts
flow charts for different for different STIs syndromes
STIs syndromes
8 Describe the main - Describe the - Describe the importance of -Mention the different -Enumerate different
features of syndromic importance of history history taking, and physical methods of diagnosis laboratory procedures
case management taking, and physical examination. in STIs and interpretations of
examination. results.
- Mention different - Mention different laboratory
laboratory investigation investigation which enables
which enables to to diagnose STIs
diagnose STIs
74
Learning activities
No. Learning Objectives HO PHN ENHS MLT
9. To describe prevention and - Explain different - Explain different - Explain different - Explain different methods
control measures of STIs methods of methods of methods of of prevention and control
prevention and prevention and prevention and of STIs.
control of STIs. control of STIs. control of STIs.
10. To recognize the role played - Mention the role - Mention the role - Mention the role - Mention the role played
by each category of the played by each played played by each by each category of
health center team including category of health by each category of category of health health center team
community health workers center team health center team center team including CHW
(CHW) including CHW including CHW including CHW
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Table 4.2: Attitude, Objectives and Activities
Leaving Activities
No. Learning Objectives HO PHN EHS MLT
1 To appreciate the - Believe that STIs are - Believe that STIs are - Believe that STIs are - Believe that STIs are
public health major health problems major health problems major health problems major health problems
importance of STIs in in Ethiopia in Ethiopia in Ethiopia in Ethiopia
Ethiopia
2 To believe that STIs - Realize the need for - Realize the need for - Realize the need for - Realize the need for
can lead to serious early detection and early detection and early detection and early detection and
complications treatment of STIs to treatment of STIs to treatment of STIs to treatment of STIs to
prevent complication prevent complication prevent complication prevent complication
3 To believe that some - Appreciate the clinical - Appreciate the clinical - Appreciate the clinical - Appreciate the clinical
STIS can be features of different features of different features of different features of different
recognized by their STIs STIs STIs STIs
clinical features
4. To believe that STIs - Believe that STIs are - Believe that STIs are - Believe that STIs are - Believe that STIs are
are caused by specific caused by micro- caused by micro- caused by micro- caused by micro-
micro-organisms organisms organisms organisms organisms
5 To believe that there - Appreciate that there - Appreciate that there - Appreciate that there - Appreciate that there
are risk factors for the are preventable risk are preventable risk are preventable risk are preventable risk
transmission and factors which factors which factors which factors which
acquisition of STIs. predispose a person to predispose a person to predispose a person to predispose a person
STIs. STIs. STIs. to STIs.
76
Leaving Activities
No. Learning Objectives HO PHN EHS MLT
6 Appreciate advantages that - Appreciate using flow - Appreciate using flow - Appreciate using flow - Appreciate using flow
syndromic case charts in charts in charts in charts in
management offers management of STIs. management of STIs. management of STIs. management of STIs.
7. To believe that syndromic - Believe that - Believe that - Believe that - Believe that
approach is an appropriate syndromic approach syndromic approach syndromic approach syndromic approach
method of diagnosing STIs is an effective method is an effective method is an effective method is an effective method
in developing countries in diagnosing STIs in diagnosing STIs in diagnosing STIs in diagnosing STIs
8 To believe that there are - Believe that STIs can - Believe that STIs can - Believe that STIs can - Believe that STIs can
specific diagnostic methods be diagnosed with be diagnosed with be diagnosed with be diagnosed with
of STIs specific methods specific methods specific methods specific methods
9 To be convinced that STIs - Believe that STIs can - Believe that STIs can - Believe that STIs can - Believe that STIs can
are preventable be prevented be prevented be prevented be prevented
10. To appreciate the role/task - Get convinced that - Get convinced that - Get convinced that - Get convinced that
played by the health center each health center each health center each health center each health center
team members in team member has a team member has a team member has a team member has a
management, prevention role to play in STI role to play in STI role to play in STI role to play in STI
and control of STIs management management management management
77
Table 4.3: Practice, Objectives and Activities
Learning Activities
No. Leaving Objectives HO PHN EHS MLT
1 - To identify possible - Assess for complications - Assess for complications -
complications of STI resulting from STIs resulting from STIs -
- Manage complications of - Manage complications of
STIs STI - -
- Educate about - Educate about - Educate about - Educate about
complications of STIs complications of STIs complications of STIs complications of STIs
2 - To enlighten the - Carry out health - Carry out health - Carry out health - Carry out health
community on the education on the the education on the education on the education on the
public health public health importance importance of STIs importance of STIs importance of STIs
importance of STIs of STIs
3 - To assess the clinical - Carry out physical - Carry out physical
features of STIs examination of STI examination of STI - -
- Give health education patients
regarding prominent - Give health education - Give health education - Give health education
signs and symptoms of regarding prominent regarding prominent regarding prominent
STIs signs and symptoms of signs and symptoms of signs and symptoms of
STIs STIs STIs
4 - To identify risk factors - Take history to identify - Take history to identify - -
of STIs risk factors for STIs risk factors for STIs - Conduct community - Conduct community
- Conduct community - Conduct community surveys on pre- surveys on pre-
surveys on pre- surveys on pre-disposing disposing factors of disposing factors of
disposing factors of STIs factors of STIs STIs STIs
- Give health education on - Give health education on - Give health education - Give health education
risk factors of STIs risk factors of STI on risk factors of STIs on risk factors of STIs
5 - To apply syndromic - Use syndromic approach - Use syndromic approach
approach in STIs to manage STI cases to manage STI cases
management
78
Learning Activities
No. Leaving Objectives HO PHN EHS MLT
6. - To conduct different - Carry out history taking - Carry out history - Conduct specific
STIs diagnostic and physical examinations taking and physical - laboratory tests for STIs
methods to diagnos STIs examinations to - Record and report
- Write specific laboratory diagnose STIs results
test requests - Write specific - - Do quality control tests
- Interpret laboratory results laboratory test - Give health education on - Give health education
- Give health education on requests diagnostic methods of on diagnostic methods
diagnosis methods of STIs - Interpret laboratory STIs of STIs
results
7. - To carry out - Give health education on - Give health education - Give health education - Give health education
preventive and prevention and control on prevention and on prevention and on prevention and
control measures measures. control measures. control measures. control measures.
of STIs - Detect cases and contacts - Detect cases and - Educate the advantages - Educate the advantages
early and treat contacts early and of prompt visits to health of prompt visits to health
- Counsel and demonstrate treat institutions and the need institutions and the need
proper condom utilization - Counsel and for contact tracing. for contact tracing.
demonstrate proper - Educate and - Educate and
condom utilization demonstrate proper demonstrate proper
condom utilization condom utilization
8. - To practice team - Exercise team approach in - Exercise team - Exercise team approach - Exercise team approach
work in management, prevention approach in in management, in management,
management, and control of STIs management, prevention and control prevention and control
prevention and prevention and control of STIs of STIs
control of STIs of STIs
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UNIT FIVE
Glossary
Counseling: Counseling is an ongoing dialogue and relationship between
client or patient and counselor
Invitro: In the test tube, chemical reaction, temperature, etc., occurring
there in.
Invi-vo: In the living being, in the living body referring to vital chemical
processes, etc as opposed to occurring in the test tube.
Syndrom: Aggregate of symptoms associated with any morbid process.
Abbreviation
CMV: Cytomegalo virus
ELISA: Enzyme Linked Immuno Sorbent Assay
FTA: Fluoresent Treponemal Antibody
HBV: Hepatitis B virus
HIV: Human Immunodeficiency Virus
IUD: Intra Uterine Devise
LMP: Last Menstrual Period
PQRST: Pain type, Quality of pain, Radiation of pain, and relief of pain,
Symptoms associated with pain, Timing of pain.
RPR: Rapid Plasma Region
STI: Sexually Transmitted Infection
TPHA: Treponema Pallidum Heamagglutination
VDRL: Veneral Disease Research Laboratory
WHO: World Health Organization
80
UNIT SIX
BIBLIOGRAPHY
1. Abrams Collins A. Clinical drug therapy – Rational for Nursing practice: 3rd
edition, J.B Lippincott company, Philadelphia, Pennsylvania ( PP: 405-452)
2. Adel A.F Mohammed, Tropical and Geographical Medicine, 2nd ed., 1993.
7. Cheesbrough, Medical laboratory manual for tropical countries, Vol II, 3rd ed,
1991, Cambridge.
10. Ethiopian Journal of Health Development Vol. 14, No. 1 April 2000.
12. Family Planning Manual for Health Workers, MOH, FGAE 1996.
14. Family Planning /Reproductive Health Issues including HIV/AIDS and other
STDs in three project focus zones in Oromyia Region, Ethiopia.
81
18. Mackie and McCartney, Practical Medical Microbiology, 13th ed 1989
Longman.
20. Ministry of Health, FDRE National guideline for management of STIs, AA.
21. Morbidity and Mortality Weekly Report, 1998, Guidelines for Treatment of
sexually Transmitted Diseases January 23, 1998 /vol. 47/NoRR – 1.
22. National guide line for the management of sexually transmitted infections
using the syndromic approach. Ministry of health, disease prevention and
control department. HIV/AIDS and other STIs prevention and control team.
November 2001.
24. Park’s Text book of preventive and social medicine 15th edition, 1997.
29. The Lancet, sexually transmitted disease Vol. 351. 1998 (suppl 111): 2 – 4
and (suppl 111) 29 – 32.
30. WHO, AIDS series 8: Guidelines for counseling about HIV infection and
disease, 1990.
82
UNIT SEVEN
ANNEX
7.1. Answer key to Pre- and Post-test
Part I: Answer Keys for the pre- and pos- tests for all categories of the Health
Center Team
1. True
2. False
3. False
4. False
5. True
6. True
7. False
8. False
9. True
10. True
11. True
12. False
13. False
14. C
15. E
16. E
17. C
18. E
19. Urithral discharge and burning on urination
20. Pelivic inflammatory diseases (PID)
21. N. gonorrhea and C.trochomatis
83
22. - Many more people live in or travel to large cities separated from
their families.
- Many people become sexually active before marriage.
- The impact of drug resistance
- Low level of awareness about STI
- Lack of behavioral change among sexually active individuals
23. Sexual transmitted infections are infections that are passed from one
person to another through sexual contact.
24. - Is simple, inexpensive, rapid and can be implemented in large scale
- Requires minimum training and can be used a broad range of health
workers, and
- It allows for diagnosis and treatment in one visit
25. - Safer sexual behavior
- Education regarding the prevention of STI
- Early detection and treatment of cases
- Identification, notification and evaluation of sexual partners
- Counseling
26. - Commercial sex workers
- Long distance truck drivers
- Adolescents
- Military personnel
- Prisoners
27. - Community leaders
- Religious leaders
- Community health worker
28. Because of:
- its high magnitude
- its potential serious complication
- its linkage with HIV/AIDS
84
Part II: Answer Keys for the pre- and pos-tests specific to each of the
professional categories.
85
3. Counseling is need directed and focused on immediate problem of an
individual based approach while health education is not.
5. Side effects: nausea, vomiting, sore mouth, white patches on oral mucosa,
diarrhea, and skin rashes; contraindications: pregnant mother, child before 8
years and lactating mothers; accuracy in administration, administration 1-2
hours before antacids or milk, administration 1-2 hours after meal.
86
7.2. Flow Charts
• Educate
No Any Ulcer(s) • Counsel
Discharge present? No
• Promote and
Provide condoms
Yes Yes
7 days
Yes
87
Treatment for urethral discharge syndrome:
Treat your patient for gonococcal and chlamydial infections. The recommended
treatment regimens are as shown below:
Give Ciprofloxacin 500mg orally single dose
Or
Spectinomycin 2gm I.M. single dose
Or
Norfloxacin 800mg orally single dose
Or
Ceftraxone 250mg I.M. single dose
Plus
Doxycyclline 100gm orally twice daily for 7 days
Or
Tetracycline 500gm orally four times daily for 7 days.
Or
Erythromycin 500mg orally four times daily for 7 days.
88
Flow Chart 2-1: Vaginal discharge syndrome (No speculum examination)
No
Yes
Yes
Refer
* Treat for gonococcal, chlamydal and trichomonial infections
89
Flow Chart 2-2: Vaginal discharge syndrome (with speculum examination)
No
• Treat for virginities only
• Educate
Endo-cervical discharge present • Counsel
No
on speculum examination? • Promote and provide condoms
• Treat partner for trichomoniasis
• Advise return after 14 days
Yes
Yes
Refer
90
Treatment for vaginal discharge syndrome:
If the risk assessment is negative, treat the patient with Metronidazole plus
Nystatin or Clotrimazol.
In the presence of risk factors treat with Ciprofloxacin 500mg orally single dose
Or
Spectinomycin 2gm 1m single dose
Or
Ceftriaxone 250mg im single dose
Or
Norfloxcin 800mg orally single dose
Plus
Doxycyclline 100gm orally twice daily for 7 - 14 days
Or
Tetracycllin 500mg orally four times daily for 7 days
Or
Erythromycin 500mg orally four times daily for 7 days
Plus
Metronidazole 2gm orally single dose
Or
Metronidazole 500mg orally four times daily for 10 days
Plus
Clotrimazole vaginal suppositories 200mg at bed time for 3 days
Or
Nystatine 100,000 units (one pessary) inserted intra-vaginally daily at
night for 14 days.
N.B.
Except in Candidiasis and bacterial vaginosis, which are not usually sexually
transmitted, partners should be included in the management of all causes; mainly
gonococcal, chlamydial, and trichomonal infections should be treated.
91
Flow Chart 3: Genital Ulcers Syndrome
Examine
• Educate
Ulcer present? No • Council
• Promote and provide condoms
Yes
• Treat for herpes
• Educate
Ulcer with vesicles or recurrences Yes • Counsel
• Promote and provide condoms
No
Examine
Yes
Examine
92
Treatment for genital ulcers syndrome:
If there are vesicles associated with the ulcer treat for Herpes genitalis.
Acyclovir 200mg orally 5 times daily for 7 days: this can shorten the duration of
the primary illness (first episode for ulcer).
93
Flow Chart 4: Lower Abdominal Pain in the Female
No
• Reassure
Pain on moving cervix and temperature
No • Follow up in 3 days, if pain
38°C or higher? persists
Yes
Yes
• Complete treatment
* Treatment for gonococcal and chlamydial infections
• Return if pain persists
94
Treatment for lower abdominal pain syndrome in the female:
Recent male sexual contacts should be treated for Gonorrhea and chlamydial
infections.
95
Flow chart 5: Scrotal swelling
No
• Reassure patient/educate
Swelling scrotum? No • Promote and provide condoms
Yes
No
14 days
No Yes
96
Treatment for scrotal swelling syndrome
Or
Or
Or
Plus
Or
Or
Plus
Supportive therapy with bed rest, scrotal elevation with scrotal support and
analgesics.
97
Flow Chart 6: Inguinal Bubo
No
14 days
Yes
Presume cured
98
Treatment for inguinal bubo syndrome:
If the bubo become fluctuant pus should be aspirated with a needle every third
day until it is dry. The aspiration should be done through a normal skin.
N.B: Direct incising and drainage should not be attempted over the lymph node.
Sexual contacts should get the same treatment.
99
Flow Chart 7: Ophtalmia Neonatorum
Yes
Yes
• Reinforce education
• Complete treatment
• Presume cured
100
Treatment for Ophtalmia neonatorum
101
7.3. Gram Staining Technique
2. Cover the fixed smear with crystal violet stain for 30 - 60 seconds.
3. Rapidly wash off the stain with clean water. If the tap water is not clean, use
filtered water or clean boiled rain water.
4. Tip off all the water, and cover the smear with Lugol’s iodine for 30 - 60
seconds.
7. Cover the smear with neutral red (safranin) stain for 2 minutes.
9. Wipe the back of the slide clean and place in a draining rack for the smear to
air dry.
10. Examine the smear microscopically, first with the 40 x objective to check the
staining and then with the oil immersion objective to look for bacterial and
cells.
Result
Gram positive bacteria Dark purple
Yeast cells Dark purple
Gram negative bacteria Pale to dark red
Nuclei of pus cells Red
Epithelial cells Pale red
102